Knowledge is key – improving patients’ oral health

The importance of plaque control to maintain healthy oral conditions is a well-known fact. Removal and disruption of the biofilm along the gingival margin and interdentally is essential in the prevention of gingivitis, periodontitis and caries.

From below studies, we learn what level of self-performed plaque control is realistic to expect from our patients, that we need to educate our patients in the dental field, focusing our efforts on interdental cleaning, and that we most likely need to individualize and repeat our information and instructions to receive the best result.

Instructions on toothbrushing – does it make a difference?

No difference between manual and different power toothbrushes with and without specific instructions in young, oral healthy adults - results of a randomized clinical trial. Schmalz G et al.

This study was conducted in a group consisting of young and oral healthy adults. The aim was to investigate what impact a single instruction within a group using oscillating-rotating electrical toothbrushes, sonic active toothbrushes or manual toothbrushes has on the outcome, measured in terms of plaque removal and reduction of gingival inflammation.

Half of the participants in each toothbrush group received one single instruction on how to use the device, while the other half did not get any instruction. Those who were given instructions in the groups using electrical toothbrushes were instructed according to the manufacturer's recommendations, while those who were given instructions in the manual toothbrush group were instructed to use the Fones' technique. All participants were told to brush twice a day for 2-3 minutes and not to use any other oral hygiene devices. They all used the same type of toothpaste.

After the 12 week test period, the results showed that neither the type of toothbrush, nor the single brush-specific instruction had any impact on plaque removal or reduction of gingival inflammation.

Instruction on one single occasion may be close to reality in daily practice regarding young, oral healthy adults, but according to the results in the present study, it does not contribute to the effectiveness of toothbrushing, independent of the type of toothbrush.

Knowledge impacts the quality of cleaning

What can we expect from our patients when it comes to self-performed oral hygiene? To find out what can be considered an upper level, this study assessed the oral cleanliness of dental staff. 127 participants, university dentists, dental students, and dental assistants, were included in the study.

Prior to performing an oral hygiene procedure, a clinical examination was conducted including dental status, papillary bleeding index, probing pocket depths, marginal plaque index and a full crown plaque index. The participants were then asked to clean their teeth to the best of their ability using manual devices. Manual toothbrushes, different kinds of toothpaste, and various devices for interdental cleaning were provided.

Afterwards, plaque was measured again. More than 95% of the participants achieved oral cleanliness at 70% or more of their gingival margins and 50% showed oral cleanliness at more than 94% of marginal sections. The time they used to achieve these results varied between 3 and 20 minutes, as the cleaning procedure had no time limit.

The authors conclude that the levels of oral cleanliness achieved in the present study must be considered very high, especially when comparing to results from similar studies performed on laypersons where they scarcely ever reached a marginal plaque index below 50%. According to the authors, 95% of oral cleanliness at gingival margins is the upper limit for what can be expected from our patients, but 70% is probably more realistic.

Knowledge within this field is considered the main factor behind the difference in plaque reduction between professionals and laypersons, indicating that sharing of relevant knowledge is an important intervention to improve patients' oral health.

Important to put continued focus on interdental cleaning

This study, conducted in Germany, is investigating toothbrush use, dental cleaning habits, and purchase criteria in a group of dental professionals and a group of laypersons. The results are based on the answers of a questionnaire.

In the dental professional group, 93% indicated use of manual toothbrushes, while the corresponding figure in the layperson group was 89%. Soft bristles were more common in the dental professional group, but overall, medium bristles dominated in both groups. Concerning bristle profile, none of the groups had a clear opinion. The dental professionals more often preferred a shorter brush head than the other group.

The use of powered toothbrushes was 57% among the dental professionals and 37% in the layperson group. In the group of dental professionals, the duration of tooth cleaning was longer, and the use of interdental cleaning devices, floss, and interdental brushes, were statistically more frequent. In the layperson group, 38% used floss and only 5% used interdental brushes. Both groups preferred to purchase their oral hygiene devices at supermarkets and drugstores.

The authors conclude that there is a difference between dental professionals and laypersons within the investigated field. Tools for interdental cleaning were used to a small extent by the laypersons, a fact that prompts the authors to stress the importance of focusing on interdental cleaning when instructing and motivating in the field of oral home care.

Low self-awareness of periodontal disease

Self-awareness of ”Gum Disease” Among US Adults.Luo H and Wu B.

In the US population, close to half of all individuals 30 years and older suffer from periodontitis – a prevalence likely to increase in the coming years, since the population ages and retains more teeth.

This study is looking into self-awareness of gum disease among US adults. The study population included 6876 individuals, all 30 years or older, and considered representative for the US population. All participants answered the question “Do you think you might have gum diseases?” with yes or no.1293 persons answered yes, and the other 5583 answered no. Their answers were correlated to the clinical presence of periodontitis, defined as the sum of mild, moderate and severe forms of periodontitis. Gingivitis was not included in the analysis.

Among those who were diagnosed with periodontitis, 27% were aware that they suffered from the disease, and awareness was the highest in the group diagnosed with severe periodontitis. Nevertheless, in the group which had moderate and severe periodontitis, 72% were not aware that they had gum disease.

In older participants, periodontitis was more prevalent, but awareness was lower. The probability to be aware of having periodontitis was shown to be higher among patients with a diabetes diagnosis, with lung disease and among smokers. Awareness was also higher among women than men.

The conclusion in this study is that self-awareness of gum disease is low in the adult US population. The authors stress the importance of raising knowledge of oral health and awareness to improve prevention and early diagnosis of periodontitis.

Raising patient compliance through MI

This article consists of two parts; this summary will focus on the second part, concerning patient motivation and adherence.

The authors discuss the lack of compliance to oral care recommendations and possible ways to deal with it, based on available literature.

Daily oral home care is essential for successful periodontal treatment. However, adherence to recommendations is shown to be low. 30-60% of health information is forgotten after one hour and 50% of health recommendations are not followed. The traditional way of telling the patient what to do does not seem to fulfill what is needed to reach a high level of compliance. What can the clinician do?

The approach discussed in this article is to merge social and health science to achieve a behaviour change. A method which has proven effective is motivational interviewing (MI). It is based on four communication skills: open-ended questions, affirmations, reflections and summary. The approach puts the patient as an individual in the centre, and the outcome of the conversation can be an enhanced understanding, desire, and ability to change one’s own oral care behaviour and goals.

MI has shown positive results in contributing to reduced plaque scores and gingival inflammation. The authors conclude that more research is needed in this field, but also stress the importance of education in MI to improve adherence with oral self-care in patients, to make it sustainable and reduce the need for reinforcement to a minimum.

Useful methods for increased patient self-efficacy

Crucial components for long term success of periodontal treatment are the patients’ adherence to recommendations from their dental professional, as well as their level of motivation. The aim of this study was to look at the effect of motivational interviewing (MI) on patients undergoing non-surgical periodontal therapy. The treatment was performed by students.

One group of students received education in MI, including a 1-day workshop, literature, and a supervisory session. Another group of students did not receive any training in this field.

Interdental cleaning self-efficacy received higher values in the group of patients treated by the MI trained students. The clinical periodontal parameters, however, were not influenced by MI, something that can be explained by the great impact of scaling and root planing on these parameters. The study extended over six months and results might have been different if duration had been longer.

The group of students who underwent MI training scored significantly higher on MI variables compared to the untrained students, although not reaching the level recommended for MI therapists. The total duration of behaviour-related conversation did not differ between the groups, even though MI requires more open questions, which could have been assumed to take a longer time.

Cylindrical versus conical interdental brushes

The aim of this randomized controlled clinical study was to compare the effectiveness of conical and cylindrical interdental brushes with respect to plaque and bleeding scores. The subjects included in the study were patients enrolled in a supportive periodontal maintenance programme for at least one year after treatment of periodontitis.

The patients were randomly selected to use either a conical or cylindrical interdental brush. The right size was tried out and instructions were given on how to use the brush. The interdental brush was used from the buccal site. Plaque scores, bleeding upon probing and probing pocket depth were registered at baseline and at the 3-month follow-up.

Six sites per tooth, disto-vestibular, vestibular, mesio-vestibular, disto-lingual, lingual and mesio-lingual, in the 51 participating subjects were analyzed. All approximal sites with the appropriate size for an interdental brush were included. A statistically significant difference was shown in plaque and bleeding scores at lingual approximal sites, disto-lingual and mesio-lingual sites, due to an increase in plaque and bleeding scores at these sites during the test period in the group allocated to the conical interdental brushes. The authors declare the results as being dependent on the geometric differences in the shape of conical and cylindrical interdental brushes, in favour of the cylindrical shape.

Successful prevention of periodontal and peri-implant diseases

Post-treatment supportive care for the natural dentition and dental implants.

Armitage GC, Xenoudi P.

This article discusses different aspects of supportive care after treatment of mild to moderate periodontitis, and after placement of implants. A maintenance programme needs to be preceded by meticulous scaling and root planing. To maintain healthy conditions and avoid recurrence of periodontal disease, it is of utmost importance that the patient has achieved the skills for optimal oral hygiene, including toothbrushing and interdental cleaning as well as an understanding of the importance of the oral hygiene.

The therapist and patient have a shared responsibility; the role of the therapist is to enable learning and understanding of the importance of plaque removal skills, and when the patient has achieved the skills, it becomes the patient´s responsibility to put them into practice. The success of implemented measures needs to be evaluated, and if signs of inflammation persist, the cause needs to be explored and corrected.

Recall intervals must be designed according to the individual's status and risk factors, though based on the literature, 3-4 month intervals are suitable for the majority of the individuals. According to this article, review of medical and dental histories, complete oral examination, establishing whether the maintenance programme is working, evaluation of oral hygiene, and full-mouth supra- and subgingival debriment should be included in the maintenance visit. It is also stressed that insufficient oral hygiene and poor compliance to participate in the recommended maintenance programme has a correlation to recurrence and progression of the periodontal disease.

The purpose of supportive implant therapy is to prevent the development of peri-implant diseases. It should include oral hygiene instructions based on individual conditions and needs, the evaluation of relevant risk factors, and a provision of professional preventive interventions.

The conclusion stresses the importance of periodontal maintenance therapy and supportive implant therapy for long-term success, or there will be an enhanced risk of recurrence and progression of periodontitis, as well as loss of implants.

Individual therapy and peri-implant health

Impact of maintenance therapy for the prevention of peri-implant diseases: a systematic review and meta-analysis.

Monje A et al.

The main aim of this systematic review was to evaluate the impact of maintenance therapy on the incidence of the development of peri-implant diseases, in patients treated with dental implants. It included 13 articles for qualitative analyses and 10 for quantitative analyses; all concerned clinical trials on humans, and all reported the incidence of peri-implant diseases, in patients either enrolled or not enrolled in maintenance therapy after dental implant treatment.

The review presents a positive relation between implant maintenance therapy and the health of the peri-implant tissues, as well as the implant survival rate. The hypothesis of plaque-dependency should be considered the primary etiological factor for peri-implant disease, however, other contributing risk factors, such as a history of periodontitis, also need to be explored.

The authors highlight the importance of tailoring the maintenance programme according to the existing risk factors of the specific patient. A minimum recall interval of 5 to 6 months is suggested, but again, individual risk factors need to be considered. Nevertheless, it is concluded that biological complications may occur, even when the patient is enrolled in a strict maintenance therapy.

The effect of different plaque reduction methods

Primary prevention of periodontitis: managing gingivitis.

Chapple IL et al.

This is a report from the 11th European Workshop in Periodontology on primary prevention of periodontitis. The working group has focused on four different approaches: mechanical self-administrated plaque control regimes, self-administered interdental mechanical plaque control, adjunctive chemical plaque control and anti-inflammatory approaches.

A number of conclusions are drawn in this report. It is implied that professional oral hygiene instruction contributes to plaque and gingivitis reduction, and that reinforcement of the instruction may lead to enhanced results.

Furthermore, a single exercise of manual toothbrushing leads to an approximate 42% reduction of plaque scores compared with pre-brushing scores. The corresponding figure for power brushing is 46%. Meta-analyses have not shown any differences in plaque reduction between different bristle designs in manual toothbrushes. Regarding reduction of gingival inflammation, it is not reported in any meta-analysis. Greater plaque reduction is reported for re-chargeable and oscillating-rotating powered toothbrushes, compared to brushes with replaceable batteries and brushes with side-to-side movements.

Concerning interdental brushes, they have shown the highest efficacy in plaque removal and are also shown to be the most accepted interdental cleaning devices among patients. Regarding the use of floss, most studies cannot show a general effectiveness in plaque removal or reduction of gingival inflammation. According to the working group, interdental brushes are the preferable choice for interdental cleaning. Floss can be an alternative only when sites are too narrow for the interdental brush and show gingival and periodontal health. It is stressed that any method chosen for interproximal cleaning should be preceded by professional instruction.

For managing gingival inflammation and preventing accumulation of plaque, chemical anti-plaque agents have a significant impact. As to the effect of anti-inflammatory agents in managing gingivitis, they lack sufficient scientific support.

The report ends with general health recommendations: Daily toothbrushing for at least two minutes in combination with fluoridated dentifrice, and daily interdental cleaning to reduce plaque and gingival inflammation. In cases of gingivitis, adjunctive use of chemical agents can be recommended.

What factors affect the development of peri-implantitis?

Risk indicators for peri-implantitis. A narrative review.

Renvert S and Quirynen M.

This review addresses possible risk indicators for peri-implantitis. The authors state that plaque accumulation, a history of periodontitis, smoking, excess cement and lack of supportive therapy should all be considered risk indicators, but the scientific data for some is limited and the strength also varies.

Buildup of plaque around implants is associated with the development of peri-implant mucositis, which may eventually develop into peri-implantitis. To control plaque accumulation, self-performed oral hygiene is of great importance. The presence of a subgingival pathogenic microbiota with a predominance of anaerobic species is considered a risk indicator for peri-implant disease. In partially edentulous subjects, newly inserted implants can be colonized by microorganisms from adjacent teeth; the natural teeth may act as reservoirs for these pathogens. Periodontopathic bacteria have been suggested a risk indicator for peri-implant mucositis. Excess of cement is also considered a risk indicator through triggering an inflammatory response.

The above described factors are local risk factors, but there is also a group of general risk indicators investigated in this review. There is support that patients with a history of periodontitis are more likely to develop peri-implantitis. The support for genetic trait as a risk indicator is divergent, but it may have an impact on the inflammatory response and the development of peri-implantitis.

Smoking cannot, due to insufficient data, be identified as a risk factor for peri-implantitis, but should be considered a risk indicator. Regarding the connection between peri-implantitis and general diseases, like cardiovascular diseases and diabetes mellitus, evidence is limited, but there might be a relation.

Participating in a structured maintenance program improves the outcome of the implant treatment; the patient’s motivation to attend supportive care visits and to perform adequate oral hygiene are both factors to consider.

From the article we can conclude that the etiology for peri-implantitis is complex.

Promoting good oral hygiene – a daily challenge

One of the challenges that the dental profession meets in daily practice is how to promote optimal oral hygiene practices to the patients. Lack of patient motivation is often stated as the explanatory factor to this challenge, while it is also suggested that more focus should be put on toothbrushing skill and technique. The authors question if skill and changing old habits have been given enough attention.

Toothbrushing is introduced at a young age, over time becoming a routine behaviour, and as such, mostly not conscious. There is a tendency to improperly estimate features associated with the routine, like overestimating the duration.

When alteration of the technique is needed, different approaches can be considered. An existing habit, like toothbrushing, may inhibit alteration of the technique in the adult individual due to the difficulty in alteration of the implicit memory. The explanation behind this phenomenon is poorly understood, but there are several aspects to consider when it comes to behaviour change. This article puts focus on behavioural skills, an essential part in the behaviour change context. In the context of toothbrushing, it means ensuring that all phases of the behavioural skill are understood by the individual, including having access to the needed devices, time and space to perform the activity and the perceived self-efficacy to brush properly.

The authors conclude that improper toothbrushing may be successfully corrected with information, motivation and awareness of specific behavioural skills. Proactive interference (an existing habit inhibiting new learning) during the toothbrushing retraining might have a negative impact on the behavioural skill, but has so far not been considered in connection with toothbrushing retraining.

Home care important in treatment of peri-implant diseases

The main purpose when treating both peri-implant mucositis and peri-implantitis is to eliminate the established biofilm from the implant surface.

There is scientific support for mechanical therapy as the treatment choice for peri-implant mucositis. The authors of this study stress plaque control performed by the patient as an important factor for treatment success, independently of treatment choice. To ensure that the patient understands the importance of home care, the dental team needs to educate and instruct the patient in proper toothbrushing techniques and provide guidance in the choice of interdental cleaning device.

Interdental brushes or flossed interdental tape are the most appropriate options for interdental cleaning. The size of interdental brush should be chosen ensuring that the filaments fill the interproximal area. The design of the suprastructure is also important to enable good oral hygiene, and can be redesigned if necessary.

In cases of peri-implantitis, and especially more advanced conditions, surgical treatment is often necessary. But again, the authors emphasise the importance of oral hygiene, stating that nonsurgical therapy in combination with reinforcement of oral hygiene should precede surgery.

In conclusion, prevention is the best treatment of any disease, including peri-implantitis, and poor oral hygiene is a defined risk indicator for this disease. The need for a regular recall program for implant patients, including follow up of oral hygiene, is evident.

Good oral hygiene - the key to treatment success

Efficacy of patient-administered mechanical and/or chemical plaque control protocols in the management of peri-implant mucositis. A systematic review.

Salvi GE and Ramseier CA.

This systematic review reports on the efficacy of self-administered mechanical and/or chemical plaque control for managing peri-implant mucositis in patients with implant-supported restorations. The review included eleven studies, in which the plaque control intervention showed great variety. The follow-up period differed from 3 to 24 months, and the definition of peri-implant mucositis varied between some of the studies, while it was not included in some.

The result shows that the effect of several interventions, particularly chemical plaque control programs, remains to be established. The scientific evidence is limited regarding inter-proximal cleaning performed by the patient, as only one of the studies reported on the use of interdental brushes and floss.

The review highlights the importance of individually tailored oral hygiene instructions for patients rehabilitated with implant-supported restorations. The authors also emphasise that in the standard protocol for managing peri-implant mucositis, the first choice should be professionally- and patient-administered mechanical plaque control alone. They also stress the importance of treating peri-implant mucositis to prevent the development of peri-implantitis.

Effective plaque removal using interdental brushes

Efficacy of inter-dental mechanical plaque control in managing gingivitis – a meta-review.

Sälzer S et al.

This meta-review, a systematic review including only systematic reviews, compiles the effect of dental floss, woodsticks, interdental brushes and an oral irrigator used for interdental plaque removal in managing gingivitis. Six systematic reviews are included – regarding dental floss (2 studies), woodsticks (1), interdental brushes (2) and oral irrigator (1).

The magnitude of the effect of floss was small, and unclear regarding woodsticks and oral irrigator, but for interdental brushes it was large. The body of evidence was greatest for interdental brushes.

Besides the efficacy of the interdental cleaning device, patient compliance is also an important factor to value when choosing device. Compliance is highly dependent on preference and manual skills of the individual patient. Interdental brushes are shown to be considered easier to use by patients than the use of floss.

There is not one single interdental cleaning device which suits all patients and interdental spaces. Several factors need to be considered when recommending interdental cleaning devices; among them scientific evidence. This meta-review concludes that there is consistent evidence that interdental brushes are the most effective devices for interdental plaque removal. They are also the most appreciated devices for interdental cleaning among patients.

The importance of changing toothbrush regularly

The influence of the utilization time of different manual toothbrushes on oral hygiene assessed over a 6-month observation period: a randomized clinical trial (RCT).

Schmickler, J et al.

The purpose of this study was to investigate how plaque removal and gingival inflammation are affected by the utilisation time of manual toothbrushes. 96 subjects were included in the study. The subjects were divided into two groups, one group changed their toothbrush every four weeks during the 6 month trial period (renewal group) while the other group used the same toothbrush throughout the whole period (non-renewal group).

In each group four subgroups were formed: normal brush head size/soft filaments, normal brush head size/medium filaments, small brush head size/soft filaments and small brush head size/medium filaments. Plaque accumulation and gingival inflammation were assessed at baseline and after 2, 8, 12, 16 and 24 weeks. A final examination was performed after an additional 10 day period.

The results showed a significant difference between the two main groups in respect to plaque accumulation and gingival inflammation in favour of the renewal group. The initial worsening in plaque reduction occurred when the toothbrush had been used for four months, and up to this time gingival health also remained stable. After four months a reduced efficiency in plaque removal was found. The authors conclude that the effectiveness of manual toothbrushes with respect to plaque removal and the development of gingival inflammation will be reduced after four months of utilisation. The effect of filament type and brush size was not clearly established. Therefore it is recommended to change toothbrush after no more than four months, independent of filament stiffness and brush head size.

How well does a worn toothbrush clean the teeth?

Plaque-removing efficacy of new and used manual toothbrushes – a professional brushing study.

Rosema, NA et al.

The aim of this study was to compare the plaque-removing efficacy between new manual toothbrushes and 3-month-old used toothbrushes. The impact of dentifrice on plaque removal was also evaluated. The study population consisted of 50 individuals. All participants received a new toothbrush to use during a 3 month pretrial period. 48 hours prior to the end of the pretrial period no brushing was performed. The investigation was designed according to a single-use, examiner blinded, professional brushing model.

To rule out the effect of the brushing technique, the brushing was performed by one dental hygienist. In every participant four ways of brushing were performed, one in each quadrant: brushing with a new toothbrush and no dentifrice, a new toothbrush and dentifrice, an old toothbrush and no dentifrice, an old toothbrush and dentifrice. At the trial appointment pre- and post-brushing, plaque was assessed as well as gingival abrasions.

The results from this study did not show any clinically relevant differences in plaque removal efficacy comparing new and 3-month-old used toothbrushes. The instant removal of plaque was not affected by the use of dentifrice. However, the wear rate seemed to influence the efficacy of the toothbrush. The authors emphasise the need to change toothbrush when it shows signs of wear. The 3-month-old used toothbrushes showed a wide variety in wear. Regarding gingival abrasion no statistically significant difference was found.

New study on caries development in children

Effect of preventive oral hygiene measures on the development of new carious lesions.

Ashkenazi, M et al.

In this Israeli study the development of new carious lesions in relation to preventive oral hygiene measures was investigated. 651 children aged 2-18 were included in this historical prospective study. A number of factors were evaluated in relation to the development of new carious lesions: the frequency of attending periodic recall appointments, the frequency of meals, drinking between meals, toothbrushing frequency, the use of fluoridated toothpaste, the use of fluoride mouth rinse, the use of high-concentrate fluoride gel and flossing in children over the age of 11.

The result showed that eating more than 6 meals a day, regular flossing, regular use of fluoride mouth rinse and the use of high-concentrate fluoride gel was not related to the development of new carious lesions. However, the number and frequency of recalls, drinking tap water (most often fluoridated), drinking sugary drinks between meals, the frequency of toothbrushing, who brushes the child´s teeth and the fluoride concentration in toothpaste was shown to have an impact on the development of new carious lesions.

The results from this study emphasises the importance of toothbrushing twice a day and using fluoridated toothpaste, 1100 ppm (considering the age of the child). The best effect of toothbrushing was seen when the parent brushed the child’s teeth.

Choosing the correct interdental cleaning device

Comparison of interdental brush to dental floss for reduction of clinical parameters of periodontal disease: A systematic review.

Imai, PH et al.

The purpose of this systematic review was to evaluate the efficiency of interdental brushes and dental floss as adjuncts to toothbrushing for reducing gingival bleeding and dental plaque. Included studies were randomised controlled trials, including split mouth and crossover trials.

Four papers were included for the analysis on bleeding outcome and seven papers for analyses on plaque outcome. The results indicate that the interdental brush is more efficient than dental floss for reducing both bleeding and plaque. In the article an instructive flowchart is presented with practical guidelines for choosing interdental cleaning device for the patient with interdental inflammation.

First, assess the patient’s level of dexterity and motivation for daily interdental self-care. If the patient has good dexterity and/or is motivated, the next step is to determine the embrasure type. For patients with type I embrasures, dental floss should be recommended. With embrasures of type II or III, the interdental brush is the correct choice. If the patient, on the other hand, has poor dexterity and/or lacks motivation, the appropriate recommendation is interdental brushes regardless of type I, II or III embrasures.

The authors conclude that the interdental brush is an effective alternative to dental floss for reducing interproximal bleeding and plaque in booth filled and open embrasures.

Cleaning frequency and gingivitis – what is true?

Frequency of mechanical removal of plaque as it relates to gingival inflammation: a randomized clinical trial.

Pinto, TM et al.

This Brazilian study investigated how often toothbrushing and interdental cleaning is needed to prevent the development of gingivitis. 52 university students were divided in four experimental groups and instructed to brush and floss with a frequency of 12, 24, 48 or 72 hours during a test period of 30 days. The examiners were blinded to the brushing frequency.

In the 12 and 24 hour groups the mean GI remained statistically unchanged during the test period, but in the 48 and 72 hour groups GI increased significantly. The authors’ conclusion is that mechanical plaque removal is needed at least every 24 hours to prevent an increase of gingival inflammation in otherwise healthy persons. However, these results are not in consistent with the results from Lang et al. (1973) which showed that plaque removal every 48 hours is compatible with gingival health. An explanation to the diverse results could be that in the study conducted by Lang et al., the plaque removal was probably more complete due to use of disclosing solution and supervision by a dental hygienist.

Sodium fluoride – an efficient fluoride formulation

Remineralisation of carious lesions and fluoride uptake by enamel exposed to various fluoride dentifrices in vitro.

Hattab, FN

In this in vitro study, eight different dentifrices containing fluoride (F) and one placebo dentifrice were compared, in terms of remineralisation of white spot lesions, fluoride uptake in the enamel and morphological changes in the treated enamel surfaces.

All the tested fluoride dentifrices showed positive effect of the lesion depths, reduction in lesion size and overall remineralisation of the carious lesions. Dentifrices containing sodium fluoride (NaF) showed the most pronounced enhancement compared to the products containing sodium fluoride/monofluorophospate (Na/MFPF) and monofluorophospate (MFP). It was also shown that NaF and NaF/MFP increased the F uptake significantly compared to MFP. Furthermore, there were dissimilarities in the enamel surface morphologies between the different F formulas.

The author concludes that the different fluoride formulations vary in effectiveness.

Recommendations on toothbrushing techniques

An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts

Wainwright J and Sheiham A

The main objectives of this study were to ascertain the recommendations on toothbrushing technique in adults and children, from dental associations, toothpaste and toothbrush companies and professional sources.In the search for information ten countries were included: Australia, Brazil, Canada, Denmark, Finland, Japan, Norway, Sweden, the United Kingdom and the United States of America. The underlying reason for choosing these countries is that they were considered to have a significant dental research output.

For adults, the Modified Bass technique is the most frequently recommended method. Other recommended techniques are (in descending order): the Bass technique, Fones, Scrub and the Stillman technique. For children it was the Fones technique that dominated, followed by Modified Bass, Scrub and the Bass method. The results showed a wide range in toothbrushing methods recommended for adults and for children. It seems that a consensus on the superior toothbrushing technique is lacking.

Recommendations concerning toothbrushing frequency differed between the sources, but with a clear dominance for brushing twice daily. There were also variations in brushing duration recommendations, but two minutes did overweigh. In conclusion, this study highlights the need of evidence on the effectiveness of different toothbrushing techniques.

The impact of toothbrushing frequency on periodontitis

Is frequency of tooth brushing a risk factor for periodontitis? A systematic review and meta-analysis

Zimmermann H et al.

The aim of this systematic review was to clarify the impact of toothbrushing frequency on periodontitis. After selection a total of fourteen studies were included in the final meta-analysis. These studies fulfilled the inclusion criteria of presenting an association of periodontitis or alveolar bone loss with oral hygiene, where toothbrushing frequency was used as one factor for oral hygiene.

The included studies differed in age of the study group (adolescents to seniors), size of the group (94-4153) and also geographically (Europe, America and Asia). Community periodontal index, clinical attachment loss, pocket probing depth and alveolar bone loss were used individually or in combination to define periodontitis.

Concerning toothbrushing frequency a dichotomization applicable to each of the included studies was not possible. The dichotomization had to be made for each study individually to define between infrequent and frequent toothbrushing.

This meta-analysis presented a clear and highly significant association of infrequent toothbrushing and periodontitis. The impact of infrequent toothbrushing in most of the individual studies showed a trend but not so strong that the result was statistically significant.

Oral hygiene is known as one of the risk factors related to severity and progression of periodontitis. Frequency of toothbrushing is not necessarily the same as efficiency of toothbrushing, but as stated in the article a positive correlation is likely.

The effect of interdental cleaning on cardiovascular events

Use of floss/interdental brushes is associated with lower risk for new cardiovascular events among patients with coronary heart disease

Schlitt RS et al.

The purpose of this prospective longitudinal study was to investigate whether oral hygiene habits, severe periodontitis, presence of periodontopathogens in the subgingival biofilm and certain IL-6c.-174 genotypes represent independent risk factors for the incidence of new cardiovascular events. The study population consisted of 942 inpatients with diagnosed coronary heart disease. The cohort was followed for one year.

The periodontal examination included, patients were asked about the frequency of toothbrushing per day and the use of dental floss or interdental brushes to clean the interdental space. Plaque, bleeding on probing, maximal clinical probing depth and maximum clinical attachment loss were registrated. Periodontitis was defined as presence of proximal attachment loss of ≥3mm in ≥2 nonadjacent teeth. Severe periodontitis was defined as presence of proximal attachment loss of ≥5mm in at least 30% of the teeth.

23.9% of the patients brushed once a day and 74.9% more than once, and 20.1% used floss and/or interdental brushes.

The incidence of mycocardial infarct, stroke/TIA and death from cardiovascular causes was calculated at the one year follow up. Data was obtained from 941 patients, among which 7.3% had received new cardiovascular events.

During the follow up period, practice of interdental cleaning was the only factor that showed a connection with statistically significant lower incidence for new cardiovascular events. However, the group who practiced interdental cleaning was significantly younger, more often females and had a lower smoke exposure, factors that might have an impact on further cardiovascular events.